EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for David’s chest pain?

• Prompt: How do you differentiate between cardiac and non-cardiac causes?
• Prompt: What red flags would indicate an urgent/emergency condition?

Q2. What further history and investigations would be useful in this case?

• Prompt: What risk factors increase suspicion for a cardiac cause?
• Prompt: What initial investigations are essential to rule out serious pathology?

Q3. How would you explain the diagnosis and immediate management to David?

• Prompt: How do you address his concerns about a heart attack?
• Prompt: What immediate steps are needed while awaiting test results?

Q4. Outline your management plan based on the most likely diagnosis.

• Prompt: When would you refer him to the emergency department?
• Prompt: If non-cardiac, what outpatient investigations and follow-up would be needed?

Q5. What are the key preventive health strategies for David moving forward?

• Prompt: How can his cardiovascular risk be optimised?
• Prompt: What lifestyle and pharmacological interventions would you recommend?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for David’s chest pain?

Chest pain has multiple potential causes, ranging from life-threatening to benign. A structured approach is essential to differentiate between them.

• Cardiac Causes (High-risk, must exclude first):
  • Acute Coronary Syndrome (ACS) – Myocardial infarction or unstable angina. Pain is central, pressure-like, radiating to jaw/arm, worsened with exertion, relieved with rest.
  • Stable Angina – Similar to ACS but predictable with exertion and relieved by GTN/rest.
  • Aortic Dissection – Sudden, tearing pain radiating to back, asymmetric pulses, hypotension.
• Pulmonary Causes:
  • Pulmonary Embolism (PE) – Pleuritic pain, dyspnoea, tachycardia, hypoxia, risk factors (DVT, immobility).
  • Pneumothorax – Sudden sharp pain, unilateral reduced breath sounds.
• Gastrointestinal Causes:
  • Gastro-Oesophageal Reflux Disease (GORD) – Burning retrosternal pain, worse with lying flat, relieved with antacids.
  • Oesophageal Spasm – Intermittent, relieved by GTN, mimics angina.
• Musculoskeletal and Other Causes:
  • Costochondritis – Reproducible tenderness on palpation.
  • Anxiety/Panic Attack – Chest tightness, hyperventilation, paraesthesia, situational triggers.

A competent candidate prioritises urgent cardiac causes first, considering risk factors such as age, smoking, family history, and symptom characteristics.

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Q2: What further history and investigations would be useful in this case?

• Further History:
  • Characterisation of pain: Onset, duration, radiation, severity, relieving/aggravating factors.
  • Associated symptoms: Dyspnoea, diaphoresis, nausea, syncope (suggest ACS/PE).
  • Cardiovascular risk factors: Hypertension, smoking, diabetes, dyslipidaemia, family history.
  • Recent travel, immobility, leg swelling: Risk factors for PE.
  • Psychosocial history: Anxiety, stress triggers.
• Immediate Investigations (in GP or emergency setting):
  • Electrocardiogram (ECG) – ST changes, T-wave inversion, new LBBB (ACS).
  • Troponin – Elevated if myocardial injury.
  • Chest X-ray – Rule out pneumothorax, pneumonia, aortic dissection signs.
  • D-dimer (if low suspicion for PE) – Normal level rules out PE.

A competent candidate takes a structured history and prioritises investigations based on clinical suspicion.

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Q3: How would you explain the diagnosis and immediate management to David?

1. Acknowledge his concerns:
   • “I understand that you’re worried about a heart attack, and given your symptoms, we need to rule that out.”
2. Explain initial assessment:
   • “Your symptoms could be due to various causes, but we take chest pain seriously. We need to check your heart with an ECG and blood tests.”
3. Explain next steps:
   • “As your symptoms suggest possible heart disease, I recommend urgent transfer to hospital for further tests, including troponin levels.”
4. Reassure while providing safety-netting:
   • “If this is not a heart attack, we will look into other possible causes such as reflux or musculoskeletal pain.”
   • “If you develop worsening pain, shortness of breath, or feel faint, call an ambulance immediately.”

A competent candidate communicates clearly, ensuring the patient understands the urgency while feeling reassured.

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Q4: Outline your management plan based on the most likely diagnosis.

1. Immediate Management (If ACS Suspected):
   • Call an ambulance (000) for urgent transfer to ED.
   • Administer aspirin 300mg unless contraindicated.
   • Oxygen therapy if hypoxic (<94%).
   • GTN sublingual if no hypotension.
   • Pain management (e.g., morphine in hospital setting).
2. Alternative Management (If Non-Cardiac):
   • Reflux → Trial of proton pump inhibitor (PPI).
   • Musculoskeletal → NSAIDs, physiotherapy.
   • Anxiety → CBT referral, relaxation techniques.
3. Follow-up Plan:
   • If discharged from ED, arrange cardiology follow-up.
   • Lifestyle modifications and cardiovascular risk reduction (see Q5).

A competent candidate ensures appropriate triage, acute management, and follow-up.

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Q5: What are the key preventive health strategies for David moving forward?

1. Cardiovascular Risk Reduction:
   • Blood pressure control (review antihypertensives).
   • Lipid management (statins, dietary changes).
   • Smoking cessation support (if relapse risk).
   • Diabetes screening (given family history).
2. Lifestyle Modifications:
   • Exercise: 150 min/week moderate-intensity activity.
   • Dietary changes: Reduce saturated fats, increase fibre.
   • Weight loss: Target BMI <25 kg/m².
3. Ongoing Monitoring:
   • Regular GP visits for BP, lipid checks.
   • Consider stress management strategies.

A competent candidate provides practical, evidence-based preventive measures to reduce future cardiovascular events.

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SUMMARY OF A COMPETENT ANSWER

• Uses a structured approach to differentiate between cardiac and non-cardiac chest pain.
• Recognises red flags and prioritises urgent conditions like ACS, PE, and aortic dissection.
• Orders appropriate investigations, ensuring ECG and troponins are checked urgently.
• Effectively communicates risk, explaining next steps clearly while addressing patient concerns.
• Implements immediate management, ensuring urgent ED referral for suspected ACS.
• Provides long-term preventive strategies, including lifestyle modifications and cardiovascular risk management.

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PITFALLS

• Failing to recognise a cardiac cause, leading to missed ACS diagnosis.
• Not performing an ECG or ordering troponins, delaying critical intervention.
• Misattributing symptoms to reflux or anxiety without proper cardiac assessment.
• Inadequate communication, causing patient distress or lack of adherence.
• Not addressing preventive measures, missing an opportunity to reduce cardiovascular risk.

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REFERENCES

• RACGP – RACGP Guidelines on Chest Pain Assessment
• GP Exams – Pain, chest NOS

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communicates effectively and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD